Tuberculosis and undernutrition in India
Authors: Dorothy Lall
Journal: The Lancet Global Health (2023)

Tuberculosis continues to claim millions of lives worldwide, especially in India. India accounts for 28% of new tuberculosis cases annually and 38% of global tuberculosis mortality.1WHOGlobal tuberculosis report 2022.https://iris.who.int/bitstream/handle/10665/363752/9789240061729-eng.pdf?sequence=1Date: Oct 27, 2022Date accessed: August 30, 2023Google Scholar Although tuberculosis has declined in countries that have improved standards of living and income, it continues to thrive in low-income and middle-income countries.2Xue Y Zhou J Wang P et al.Burden of tuberculosis and its association with socio-economic development status in 204 countries and territories, 1990–2019.Front Med. 2022; 9905245 Crossref Scopus (5) Google Scholar We have known since the 19th century that tuberculosis is a social disease, inextricably linked to hunger, poverty, poor sanitation, poor housing, and social disadvantage. It is in this context that the study by Anurag Bhargava and colleagues (September, 2023)3Bhargava A Bhargava M Meher A et al.Nutritional support for adult patients with microbiologically confirmed pulmonary tuberculosis: outcomes in a programmatic cohort nested within the RATIONS trial in Jharkhand, India.Lancet Glob Health. 2023; 11: e1402-e1411Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar is substantial and important. The nested study of the Reducing Activation of Tuberculosis by Improvement of Nutritional Status (RATIONS) trial reports that nutritional supplementation is effective in patients with microbiologically positive tuberculosis, improving clinical outcomes including functional capacity and mortality. The full trial reported in The Lancet showed the effectiveness of nutritional supplementation to household contacts in reducing the incidence of tuberculosis by 0·9%.4Bhargava A Bhargava M Meher A et al.Nutritional supplementation to prevent tuberculosis incidence in household contacts of patients with pulmonary tuberculosis in India (RATIONS): a field-based, open-label, cluster-randomised, controlled trial.Lancet. 2023; 402: 627-640Summary Full Text Full Text PDF PubMed Google Scholar The study has garnered well deserved global and national attention for its findings, meticulous design, and execution despite the challenge of an ongoing pandemic. However, I would like to draw attention to the alarmingly high rates of undernutrition that this study reports in people with tuberculosis and the implications for policies that the paper presents. Although treating severe undernutrition with food is crucial in the short term, this solution should not divert our focus from the ongoing need for sustained attention and efforts to address the social determinants of tuberculosis. The 2023 Food Security Report reveals that, despite India having one of the lowest meal costs in the world, many people are still denied access to nutritious food.5Food and Agriculture OrganizationInternational Fund for Agricultural DevelopmentUNICEFWHOThe state of food security and nutrition in the world 2023.http://www.fao.org/documents/card/en/c/cc3017enDate: 2023Date accessed: September 1, 2023Google Scholar The policy implication extends beyond simply advocating for nutrition supplementation; it should also encourage continuous efforts to address hunger, poverty, unemployment, inequality, and systemic disadvantage or structural violence. Embracing a health in all policies approach can expand the range of interventions and help with winning the war and not just the battle against tuberculosis. I want to conclude with the wisdom of Sir William Osler that has been available to us for a century: "When workers have living wages, when the house becomes the home, when the nation spends on food what it now spends on drink, then, instead of hundreds of thousands there will be millions… with practically continued immunity against the ravages of tuberculosis".6Osler W Notes from London.https://trove.nla.gov.au/newspaper/article/33582261Date: Aug 25, 1914Date accessed: October 26, 2023Google Scholar I declare no competing interests. Nutritional support for adult patients with microbiologically confirmed pulmonary tuberculosis: outcomes in a programmatic cohort nested within the RATIONS trial in Jharkhand, IndiaIn this study, nutritional support was provided to a cohort with a high prevalence of severe undernutrition. Weight gain, particularly in the first 2 months, was associated with a substantially decreased hazard of tuberculosis mortality. Nutritional support needs to be an integral component of patient-centred care to improve treatment outcomes in such settings. Full-Text PDF Open AccessTuberculosis and undernutrition in IndiaOne of the key finding of the RATIONS trial substudy1 is a significant association between weight gain and improved treatment outcomes. The study showed that a 5% weight gain was associated with a 61% decreased likelihood of tuberculosis mortality, particularly in the initial 2 months of treatment. This resonates with the findings of previous studies2 emphasising that nutritional intervention can help improve tuberculosis cure rate. Furthermore, the median 4·6 kg weight gain in the participants supports the efficacy of nutritional support. Full-Text PDF Open AccessTuberculosis and undernutrition in India – Authors' replyThe comment by Dorothy Lall (including the gem from William Osler) is a reminder to view tuberculosis through a social lens, and the need to address poverty and the underlying social and societal determinants as a matter of human rights and social justice. These structures of inequality create risks for people and communities to multiple diseases, and the inequities in provision of care that result in multiple adverse outcomes.1 The severity of undernutrition seen in our patients was a combination of pre-existing undernutrition prevalent across sex in poor indigenous communities and disease-related undernutrition made more severe by delays in care seeking and inadequate access to care. Full-Text PDF Open Access